If you applied for ERISA benefits and the insurer denied your claim, contact the employee rights and overtime lawyers of Wallace Miller immediately. We could represent you in an appeal to recover the benefits you deserve for your injury or illness.
The Employee Retirement Income Security Act regulates employer-paid disability insurance plans, pensions, and other benefits. You are entitled to certain benefits when you can no longer earn a living due to a qualifying medical condition. The monthly payments you receive can compensate for a percentage of the gross average monthly wage you lose while out of work.
Unfortunately, some insurance companies engage in illegal or unfair practices. They might unnecessarily delay the application process, deny the claim without a valid reason, or underpay the total available benefits. When that happens, you can seek legal action. You have the option to file an appeal or lawsuit to recover the benefits you deserve.
Wallace Miller can provide the legal representation and guidance you need during the ERISA claims or appeals process. We know the type of documentation necessary to prove you have a medical condition that prevents you from earning your usual wage. We can complete every step on your behalf and fight to try to reach a favorable outcome. You can count on our team to advocate for your rights and remain by your side until the end.
Call Wallace Miller at (312) 261-6193 today for your free consultation.
Understanding ERISA
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that regulates health and retirement plans in the private industry, including:
- Disability insurance
- Life insurance
- Accidental Death and Dismemberment Insurance
These regulations are supposed to protect the people covered by these plans.
Insurance companies must provide plan participants with necessary information regarding their plans, such as:
- Minimum standards for participation
- Vesting
- Who has fiduciary responsibility for controlling and managing plan assets
- Plan features and funding
- Benefit accrual and funding
- Process for grievances and appeals
Your insurance policy falls under ERISA law if you work for an employer that funds your benefit plan. Your employer and their insurer must comply with the regulations.
Medical Conditions Eligible for Disability Benefits
According to the Americans with Disabilities Act, a disability involves:
- An actual or perceived physical or mental impairment that limits or perceivably limits a major life activity;
- A record of an impairment; or
- A physical or mental impairment that limits one or more major life activities.
Medical conditions that could qualify you for disability insurance under ERISA law include:
- Rheumatoid arthritis
- Kidney disease
- Parkinson’s disease
- Diabetes
- Hearing or vision loss
- Lupus
- Depression
- Irritable bowel syndrome (IBS)
- Chronic migraines
- HIV/AIDS
- Stroke
- Heart disease
- Post-traumatic stress disorder and other mental illnesses
- Cancer
- Multiple sclerosis
- Spinal stenosis
- Fibromyalgia
You should contact Wallace Miller immediately if you have a qualifying condition and the insurance company denied your claim for disability insurance. We can review your case and determine whether you are entitled to benefits.
Life Insurance Benefits for Beneficiaries
When employees apply for a life insurance policy, they typically name someone as the beneficiary. A beneficiary is an individual who receives benefits when a specific event occurs. In terms of life insurance policies, the specific event is the policyholder’s death.
An ERISA life insurance plan could have one or multiple designated beneficiaries. If an employee lists more than one beneficiary, they often include information regarding how much of the benefits each person will receive. It might be a specific dollar amount or a percentage of the total available coverage.
Accidental Death and Dismemberment Benefits
An accidental death and dismemberment (AD&D) plan provides benefits when an employee dies or sustains a debilitating injury in an accident. Coverage isn’t available if the death or disability is due to self-inflicted harm, old age, or a disease.
Surviving family members can recover benefits by filing an AD&D claim through the deceased’s insurance company. Most claims involve an employee’s death. However, if you are the plan participant and survive an accident but suffer a disabling or disfiguring injury, such as a loss of limb, you could receive benefits.
Applying for Benefits from an ERISA Plan
ERISA law requires covered participants to follow a specific procedure when filing a claim for benefits. You must notify your employer of the injury or illness and complete the form they provide. It’s vital to fill out each part of the application completely and accurately. Missing or inaccurate information could result in a denied claim.
Once you return the application to your employer, they should submit it to their insurance representative to start the claims process. You must include evidence of your medical condition and documentation that shows how it affects your job abilities. The evidence you provide could include:
- Hospital records from the onset of the disease or injury
- Physician statement explaining how the medical condition causes a physical or mental impairment
- Copy of your job description to show the specific tasks your employer requires as part of your employment
- Diagnostic test results
- Statements from coworkers, friends, and family who can address the impact of the injury or disease on your daily life
- Treatment records to show that ongoing medical care is necessary
- Lost wage reports indicating the hours missed from work and unearned wages
Every policy requires applicants to go through a waiting period before receiving their first benefit payment. The waiting period is the time between the date of the disability and when the coverage begins. Every policy differs but most require a waiting period of 30, 60, or 90 days. Benefits will continue for two years or until you turn 65 years old if your disability continues to prevent you from returning to work.
Common Reasons for Denied Disability Benefits
You should understand the reasons insurance companies deny disability benefit claims. You could avoid the common errors people make that result in delays and inadequate benefit payments. The most common reasons for denied claims include:
- IME appointment – Employees who can’t return to work often need to attend an independent medical examination (IME). This is a medical evaluation by a doctor the insurer chooses to determine if you have a qualifying condition. Missing the appointment could lead to a denial.
- Incomplete or inaccurate forms – The application you submit must include all necessary information regarding your injury or illness. If you don’t complete every section, it can delay the entire claims process. The insurance carrier could even deny your claim since they don’t have all the information they need to provide benefits.
- Disability definition – Every disability policy includes the definition of a disability. You could end up with a denied claim if your condition doesn’t match the definition listed on your policy.
- Lack of medical evidence – You must have evidence of an illness or injury that affects your functional capacity. Without medical documentation, you can’t prove you have a disability.
- Misrepresentation – Some insurance carriers review the claimant’s social media accounts to confirm that the disability claim is truthful. They could deny your claim if they find evidence that you exaggerated the severity of your injury or lied about its effects on your daily routine.
If you haven’t filed your ERISA claim yet, reach out to Wallace Miller today. You should never attempt to pursue benefits yourself. Without legal representation, you will likely not receive the payments you are entitled to.
What You Can Do About a Denied Claim
Denied disability insurance claims are common. Insurance companies are notorious for finding ways to save money, even if that means denying plan participants the benefits they need and deserve. A denial letter should include the reason for the denied claim and instructions on how to appeal the decision.
ERISA law requires you to file an administrative appeal within 180 days from the date on the letter you receive. You might need to gather additional documentation to submit with your appeal, depending on the reason for the denial. Appealing could be as simple as submitting a missing medical record you forgot to include with the initial application.
Sometimes, a denied claim is an honest mistake. Insurance representatives might enter information into the system incorrectly or misinterpret the evidence they review. However, there are situations when insurance companies act in bad faith.
Insurance bad faith is any act that prevents a claimant from receiving compensation they’re owed or unnecessarily delays the claims process, such as:
- Failing to investigate the claim promptly and thoroughly
- Intentionally misrepresenting or withholding details regarding coverage and the claim
- Failing to respond to emails or phone calls timely
- Denying a claim without an explanation or valid reason
- Enforcing a deadline that doesn’t align with policy documents
- Denying the payment of medical procedures, services, or supplies due to an opinion that it isn’t medically necessary without providing evidence
You could file an appeal if the insurance company acted in bad faith. Contact Wallace Miller immediately so we can begin the appeals process before time runs out. You have a right to benefits as an employee covered by an ERISA insurance plan. We won’t let the unlawful or illegal practices of the insurer keep you from the benefits you deserve.
Compensation Available for Insurance Bad Faith
If the insurance carrier acted in bad faith, you could pursue legal action and recover compensation. The compensation you receive could apply to various losses, such as:
- Emotional distress due to the misconduct
- Expenses eligible under the policy, including lost wages, medical bills, and property damage
- Additional financial losses due to the insurer’s actions
You might also be able to recover punitive damages if you file a lawsuit against the insurance company. This form of compensation punishes the defendant for their wrongdoing and is meant to deter similar behavior in the future. You must have clear and convincing evidence of the defendant’s bad faith to receive this financial award.
Contact Us
Wallace Miller will fight to protect your rights under ERISA law and seek the maximum possible benefits on your behalf. Our ERISA benefits attorneys will help you through this challenging time so you can secure your financial future and get your life back on track.
If the insurance company denied your claim for life insurance, Accidental Death and Dismemberment, or disability benefits, call Wallace Miller at (312) 261-6193 for your free consultation to see how we can help.